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Submission for OMB Review; Comment Request

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The Department of Defense has submitted to OMB for clearance, the Start Printed Page 18325following proposal for collection of information under the provisions of the Paperwork Reduction Act (44 U.S.C. Chapter 35).


Consideration will be given to all comments received by April 25, 2013.

Title, Associated Form and OMB Number: Third Party Collection Program/Medical Services Account/Other Health Insurance; DD Form 2569; OMB Control Number 0720-TBD (previously OMB Control Number 0704-0323).

Type of Request: Extension.

Number of Respondents: 2,936,905.

Responses per Respondent: 1.

Annual Responses: 2,936,905.

Average Burden per Response: 3 minutes.

Annual Burden Hours: 146,845.

Needs and Uses: The information collection requirement is necessary to obtain health insurance policy information used for coordination of health care benefits and billing third-party payers. DoD implemented the Third Party Collection Program (TPCP) in FY87 based on the authority granted in 10 U.S.C. 1095 and implemented by 32 CFR part 220 in accordance with the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA) (Pub. L. 99-272, section 2001, April 7, 1986). Under the TPCP, DoD is authorized to collect from third-party payers the cost of inpatient and outpatient services rendered to DoD beneficiaries who have other health insurance. Military treatment facilities are required to make this form available to third-party payers upon request. A third-party payer may not request any other assignment of benefits form from the subscriber.

Affected Public: Business or other for-profit; individuals or households.

Frequency: Annually or on occasion (when insurance information changes).

Respondent's Obligation: Required to Obtain or Retain Benefits.

OMB Desk Officer: Mr. John Kraemer.

Written comments and recommendations on the proposed information collection should be sent to Mr. Kraemer at the Office of Management and Budget, Desk Officer for DoD, Room 10236, New Executive Office Building, Washington, DC 20503.

You may also submit comments, identified by docket number and title, by the following method:

Instructions: All submissions received must include the agency name, docket number and title for this Federal Register document. The general policy for comments and other submissions from members of the public is to make these submissions available for public viewing on the Internet at as they are received without change, including any personal identifiers or contact information.

DOD Clearance Officer: Ms. Patricia Toppings.

Written requests for copies of the information collection proposal should be sent to Ms. Toppings at WHS/ESD Information Management Division, 4800 Mark Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100.

Start Signature

Dated: March 12, 2013.

Aaron Siegel,

Alternate OSD Federal Register Liaison Officer, Department of Defense.

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[FR Doc. 2013-06852 Filed 3-25-13; 8:45 am]